11 January 2007

Been a downer week here in the ED. Seen a lot of sick people with devastating neurologic injuries, several of whom have died, and none of the survivors will have any sort of a happy outcome.

This was a young-ish lady with thin blood due to liver problems. She was watching TV on the couch with her husband and cried out suddenly and went limp, as her extremely caring husband cradled her. She came in intubated with a GCS of three (deeply comatose). The white stuff on the left side of the brain is a whole lotta blood. This is a non-survivable event. After family congregated and had a change to talk it over, they decided to withdraw care and she died within six hours of admission. He husband was greatly consoled by the fact that he had been with her in her last waking moments.

This elderly man went onto the roof to clear off some tree branches from a windstorm. We think he fell trying to get back on the ladder. He has blood on the right in the subarachnoid space, and a small hematoma on the left in the subdural space; a classic coup-coutrecoup pattern of injury. This is a rather small bleed, actually, but there is diffuse injury to the entire brain, and though it has now been several days, he has not regained consciousness and probably never will.

This is a gentleman who had been transferred into our county jail from a distant facility. Less than 24 hours after arrival he was found unresponsive. Again, the white stuff is blood from an intracerebral hemorrhage, likely due to elevated blood pressure (possibly cocaine-related). In this case, the blood poured into the ventricles in the central portion of the brain, which caused sudden increase in the intracranial pressure as the normal drainage of the brain was blocked. A catheter was inserted to relieve the obstruction. He too, is deeply comatose and unlikely to survive. Sadly, nobody knows whether he has any family or friends who should be notified. As of this writing he is alive in the ICU.

This is another older man who fell down several stairs, leading with his head. This is a lateral view of the upper cervical spine, and you can see that the top portion of the second vertebra -- the odontoid -- has been knocked off and pushed backwards. What you can't see is the spinal cord which is getting compressed by the fracture fragment. (The spinal cord doesn't always show up on CT scans.) He did have family at the bedside, and he too passed away shortly after arrival.

The kicker is that it was the same neurosurgeon on call for each and every one of these cases. They all came in after midnight (except the fall off the roof). After a while the poor neurosurgeon cringed at the mere sound of my voice, just knowing that I had something awful for him. But all the badness certainly casts a pall over the department and sucks the carpe right out of your diem. Sheesh. I hope this isn't an omen for how the rest of the year is going to go.

It's pretty easy once you master the mystery of the so-called "right click." The nice thing is that doing it that way just downloads the image file and strips out the patient identifiers. Tha way I don't need to fool around with editing the image.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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